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Vol. X. NO. 19 ~ EINet News Briefs ~ Sep 21, 2007


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Portugal (Santarem): Avian influenza H5N2 reported in ducks
- Germany: Avian influenza H5N1 found in frozen duck meat
- China: Avian influenza H5N1 strikes ducks in southern China
- Indonesia (Riau): New fatal human case of avian influenza H5N1
- Myanmar (Mon, Karen): Avian influenza reported in poultry
- Australia (Queensland, Victoria): Shigellosis cases associated with Thai baby corn
- Russia (Krasnodar): Swan reportedly infected with avian influenza
- Russia (Khanti-Mansiysky): Increases in cases of tularemia
- Russia (Buryatia): Anthrax-infected meat causes hospitalization
- Viet Nam: Rabies kills 81 humans so far in 2007
- Philippines (La Union): 3 fatal human cases of rabies so far in 2007
- USA: CDC predicts record flu-shot supply, decries low coverage
- USA: GAO finds gaps in federal pandemic planning
- USA: FDA approves FluMist for 2- to 4-year-old children
- USA: Trial of injectable flu drug yields disappointing results
- Peru: HIV infections associated with blood transfusion
- USA: Animal hides were likely cause of 2 anthrax cases
- USA (Arizona): Human case of plague reported
- USA (Texas): Cutaneous leishmaniasis cases in North Texas
- USA: House panel sees CDC errors in case of traveling TB patient
- Nigeria (Nasarawa): Avian influenza reported in poultry

1. Updates
- Avian/Pandemic influenza updates
- Cholera, diarrhea & dysentery
- Dengue
- West Nile Virus

2. Articles
- CDC EID Journal, Volume 13, Number 9—Sep 2007
- Potential for early warning of viral influenza activity in the community by monitoring clinical diagnoses of influenza in hospital emergency departments
- Influenza Vaccination Coverage Among Children Aged 6-59 Months--Six Immunization Information System Sentinel Sites, United States, 2006-07 Influenza Season
- Influenza Vaccination Coverage Among Children Aged 6-23 Months--United States, 2005--06 Influenza Season
- State-Specific Influenza Vaccination Coverage Among Adults Aged >18 Years--United States, 2003-04 and 2005-06 Influenza Seasons
- Ocular and Respiratory Illness Associated with an Indoor Swimming Pool--Nebraska, 2006
- Multistate Outbreaks of Salmonella Infections Associated with Raw Tomatoes Eaten in Restaurants--United States, 2005-006
- Mucosal immunization with a novel nanoemulsion-based recombinant anthrax protective antigen vaccine protects against Bacillus anthracis spore challenge
- On Prions, Proteasomes, and Mad Cows
- The Continuing Spread of West Nile Virus in the Western Hemisphere

3. Notifications
- New avian influenza reports from the ECDC
- Seattle Influenza Vaccine Symposium, Oct. 15
- APUA Second World Congress
- MMWR Podcasts
- FDA approves Acambis smallpox vaccine
- Redefining Readiness


Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

2003 Viet Nam / 3 (3)
Total / 3 (3)

2004 Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2005 Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2006 Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 13 (8)
Djibouti / 1 (0)
Egypt / 18 (10)
Indonesia / 56 (46)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 116 (80)

2007 Cambodia/ 1 (1)
China / 3 (2)
Egypt / 20 (5)
Indonesia / 31 (27)
Laos / 2 (2)
Nigeria / 1 (1)
Viet Nam 7 (4)
Total / 65 (42)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 328 (200).
(WHO 9/10/07 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm. (WHO/WPRO 9/10/07)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 9/21/07): http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 9/11/07): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html.

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Europe/Near East
Portugal (Santarem): Avian influenza H5N2 reported in ducks
The H5N2 virus was discovered in 2 farms that rear ducks in Vila Nova da Barquinha and in Tomar. The Ministry of Agriculture assures that all the infected birds have been killed. The farms are free range, though, which makes it impossible to know how many animals may have been in contact with the disease. The H5N2 strain is considered to have a low pathogenicity, making it less dangerous. Nevertheless the authorities have placed both farms under the surveillance of the Bird Flu Vigilance Plan. (Promed 9/18/07)

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Germany: Avian influenza H5N1 found in frozen duck meat
A government official in Bavaria said there was a chance that some frozen duck meat contaminated with the H5N1 avian influenza virus made its way to consumers' tables. The virus was found in 18 frozen ducks from a batch sample at a poultry company slaughterhouse. The birds are from a processor in the town of Wachenroth, which is the location of Germany's most recent H5N1 poultry outbreak. After the disease struck 4,000 birds at Wachenroth, officials culled more than 129,000 birds. In Aug 2007, more than 160 000 ducks were slaughtered at another Bavarian poultry farm following an outbreak. Meanwhile, German officials culled more than 205,000 birds at 2 nearby farms in Trumling and Hofing because the 2 facilities have business ties to the affected Wachenroth site; the birds didn't appear sick but were destroyed as a precaution, because blood tests showed they had antibodies to the H5N1 virus. Roland Eichhorn, a Bavarian consumer affairs minister, said that at the first sign of the outbreak, authorities impounded all meat produced on the farms on or after Jul 30. Officials believe the outbreak began Aug 1, 2007. However, Eichorn said he couldn't rule out the possibility that some of the infected meat reached food stores and was sold to consumers. But if it was, the health risk would be low, he asserted. "This type of duck is casseroled, and then the meat poses no danger to the consumer," he said. According to WHO, cooking poultry to 70C kills the H5N1 virus, and so far humans have not gotten sick from eating properly cooked poultry, even if the meat contained the virus before it was cooked. Several human H5N1 cases have resulted from eating improperly cooked poultry. Also, unsafe food-handling practices could allow the virus to spread from raw poultry to other foods to be eaten raw.
(CIDRAP 9/10/07; Promed 9/8/07)

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Asia
China: Avian influenza H5N1 strikes ducks in southern China
Close to 10,000 ducks died recently of H5N1 avian influenza in a village in southern China not far from Hong Kong, and a local official said the ducks had been vaccinated against the virus. In China's first H5N1 outbreak since May, 9,830 ducks died of the disease and another 22,800 were destroyed to keep it from spreading, according to a report that Chinese officials filed Sep 15, 2007. The outbreak began Sep 5, 2007. The disease struck in a village near Guangzhou, Guangdong province. Hong Kong news media had reported that 100,000 additional ducks were culled by local officials to contain the disease. A total of 68 poultry farmers who have had close contact with ducks killed by bird flu have taken blood tests and medical checkups, and were found to be in good condition. The district government announced 18 Sep 2007 the suspension of all poultry markets within a 13 km radius surveillance zone. Reportedly, the district would put more pork, beef, and fish on the market to meet the needs of local consumers.

Yu Yedong, director of the Guangdong Animal Epidemic Prevention Centre, said the ducks had been vaccinated. He said he believed the ducks became infected after the first of a scheduled 2 doses of vaccine. 1 dose is 65% effective and 2 doses are 90% effective, Yu said. Ho Pak-Leung, an infectious disease expert at Hong Kong University, said the outbreak triggered fears in Hong Kong that the virus has mutated or the vaccine has become ineffective. A UN Food and Agriculture Organization (FAO) report says that poultry typically require 2 doses of vaccine for "adequate" protection against highly pathogenic avian flu viruses. Vaccinated birds usually are not fully protected from infection, but they have increased resistance and, if they become infected, suffer milder disease and shed less virus. Yu also said that although almost all poultry in the province had been vaccinated, it took at least 21 days for vaccines to create enough antibodies in birds.

Hong Kong Health Secretary York Chow said Hong Kong had imposed a 21-day ban on imports of live poultry, eggs, and meat from farms near the outbreak site. Hong Kong New Territories Poultry-Culture (geese and ducks) Mutual Aid Association said the outbreak has led to a 20 to 30 per cent drop in poultry sales. China has suffered huge economic losses from outbreaks of animal diseases. It is estimated that animal diseases cost China 40 billion yuan [USD 5.31824 billion] annually.
(CIDRAP 9/17/07; Promed 9/18/07, 9/19/07)

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Indonesia (Riau): New fatal human case of avian influenza H5N1
The Ministry of Health of Indonesia has announced a new case of human infection of H5N1 avian influenza. A 33-year-old male plantation worker from Riau Province developed symptoms 25 Aug 2007, was hospitalized 2 Sep 2007 and died 6 Sep 2007. His source of exposure is currently under investigation. Reportedly he had bought 2 live chickens at a local market.
(Promed 9/10/07; Promed 9/7/07)

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Myanmar (Mon, Karen): Avian influenza reported in poultry
A UN official has confirmed a fresh outbreak of avian influenza in the southern state of Mon, which borders Thailand in the south of the country. An adviser to the Burmese government with the Food and Agricultural Organization (FAO) said "We have had an outbreak in Mon state. [A total of] 500 chickens were culled, but it is now under control." The H5N1 virus hit poultry in the Dawn Zayat quarter of Maulmein township. A second outbreak was also reported in Pa-An township in neighboring Karen State. There have been 2 outbreaks of bird flu in Mon state already this summer [2007].
(Promed 9/7/07)

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Australia (Queensland, Victoria): Shigellosis cases associated with Thai baby corn
Queensland Health has investigated 11 laboratory-confirmed cases of Shigella sonnei with most cases having reported either consuming imported baby corn from Thailand or eating at a venue where imported baby corn was commonly served. These cases included 2 from another state, Victoria, who had traveled to Queensland. 4 cases were part of a larger outbreak with a further 43 probable cases (with symptoms including acute diarrhea with or without vomiting, stomach cramps, and fever between 9 and 14 Aug 2007). Another 2 cases were infected while hospitalized and a further 2 cases ate at a common holiday resort. The dates of onset of illness among the 11 laboratory-confirmed cases were from 9 to 27 Aug 2007. The median age of cases was 31 years (range 18-76 years) and 7 cases were female.

Results of pulsed field gel electrophoresis (PFGE) testing of the human isolates from Queensland show a profile that is indistinguishable from that of human isolates from a recent outbreak in Denmark (also Shigella sonnei cases associated with baby corn consumption) using the enzyme XbaI and the same running conditions as Denmark. The traceback investigation to date shows that 8 of the 11 cases may have eaten baby corn that was part of a very small consignment imported Jul 2007 by a single wholesaler in Queensland from an agent in Thailand. Microbiological testing of baby corn from current batches is currently underway, although there was no leftover baby corn from the original consignment for testing. Australia is attempting to trace the source of the baby corn with the assistance of Thai authorities. Onset date of illness for the last reported case was 27 Aug 2007, and therefore no product recall has been initiated. Most baby corn commercially available is grown and processed in Asia, particularly in Thailand. It has been an extremely important crop in Thailand since 1976, and other Asian nations have also begun producing and exporting it.
(Promed 9/13/07)

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Russia (Krasnodar): Swan reportedly infected with avian influenza
Laboratory tests have confirmed that a dead swan found in the Krasnodar Territory was infected with H5 bird flu virus, but not with the N1 strain, a source in the local administration said 10 Sep 2007. This is the only case of bird flu detected in the territory since 410 chickens died from the virus and 22 000 birds were culled at a local poultry farm in southern Russia. A regional laboratory identified the lethal H5N1 virus in the dead chickens, and took steps to contain the spread. The losses from the outbreak are estimated at 20 million rubles (USD 702 000).
(Promed 9/11/07)

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Russia (Khanti-Mansiysky): Increases in cases of tularemia
In Berezov district (Khanti-Mansiysky autonomous region), the number of patients with tularemia has increased to 23 persons. It is reported that, all infected persons, among them 3 children, have been hospitalized. It is thought that rodents are the source of infection. Rodents' burrows were flooded because of high level of water, therefore the animals had to search for new habitation close to [human] settlements. Insects may have played a significant role in transmission of infection. In Russia, tularemia cases are reported, with 100-400 cases annually; 70 percent of cases are in the Northern, Central, and Western-Siberian areas of Russia. Seasonal variations of tularemia morbidity are varied in different zones and depend on a number of reasons (including the activity of infected rodents, activity of carriers (insects), and activity of people). In addition to transmission of F. tularensis related to contact with infected animals and via arthropod bites, the infection can be spread through water.
(Promed 9/10/07)

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Russia (Buryatia): Anthrax-infected meat causes hospitalization
On 29 Aug 2007 a sick animal was slaughtered in Kyren village, in the Tunkinskoyo [Tunkinsky] district, without the presence of a veterinarian. A total of 5 people attended the slaughter. To confirm the suitability of the meat, the owner sent biological material (liver, heart) to be examined in the [local?] Veterinary Laboratory, which tentatively suspected anthrax. On 31 Aug 2007 material was confirmed to have anthrax. All 18 people who were in contact with the sick animal and the contaminated meat were placed under medical observation. Anthrax has been diagnosed in an inhabitant of Tunkinsky who participated in the slaughter, and he has been hospitalized. A total of 500 doses of a human anthrax vaccine and 10 000 doses of animal vaccine have been delivered in the district. The background to the case and to exposure of persons who are not animal owners is the lack of [cattle] vaccination. There are 25 locations in the Tunkinsky district where anthrax had been recorded in the past. The authorities urge the public to purchase meat and meat products only from recognised, veterinary-controlled sources and to avoid any purchase from unknown persons.
(Promed 9/9/07)

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Viet Nam: Rabies kills 81 humans so far in 2007
81 people in Vietnam died of rabies in the first 8 months of this year, a local newspaper reported 10 Sep 2007. Most of the victims were from the northern provinces of Tuyen Quang, Phu Tho, Ha Tay and Yen Bai. Viet Nam has annually reported 80 fatalities due to rabies since 2004, up from only 34 in 2003. Nearly 5.9 million people in Viet Nam have been bitten by rabies-infected dogs or cats in the last 10 years, much higher than the figure in the pre-1996 period. Viet Nam is encouraging vaccinations among people and dogs in a bid to contain the disease by 2010 and eradicate it by 2015.

Rabies is a significant zoonotic disease worldwide that is also on the list of vaccine preventible diseases. Major vaccination programs of domestic animals in countries have resulted in significant reductions in human rabies as the majority of cases in developing countries are a result of bites by rabies infected domestic animals such as dogs and cats. With respect to human disease, adequate post-exposure vaccination (using rabies hyperimmune globulin combined with locally available rabies vaccine) has a high efficacy in preventing human disease.
(Promed 9/10/07)

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Philippines (La Union): 3 fatal human cases of rabies so far in 2007
Dogs have been causing an outbreak of disease in Bauang, La Union [province], prompting officials to join hands in vaccinating all dogs in the town and neighboring areas due to an upsurge in rabies cases. Provincial agriculturist Avelino Lomboy said the Bauang officials declared the town under a state of calamity after 95 people were reported to be exposed to rabies. Since Jan 2007, 3 people have died [of rabies]. The highest number of cases came from the villages of Central West and Parian Weste. The provincial government vaccinated 450 dogs in the town, while the Bauang government was ready to buy more anti-rabies vaccines, he said. "We are undertaking massive anti-rabies vaccination, with personnel going around the villages giving dogs the needed shot," he said. The provincial government asked the national government for more anti-rabies vaccines so they could undertake a province-wide vaccination.

Bauang has an ordinance prohibiting stray dogs. The penalty is P 1000 [about USD 22] for every unconfined dog. "But the local government is having a difficult time in implementing it," Lomboy said. In Bulacan, officials in Bustos town have been calling for the mandatory vaccination of pet dogs there to prevent rabies infections. Through a provincial board resolution, the Bustos local government placed Barangay (village) Liciada under a state of calamity to facilitate the immediate release of funds for vaccination and medical needs associated with rabies.
(Promed 9/18/07)

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Americas
USA: CDC predicts record flu-shot supply, decries low coverage
Predicting that this year's supply of influenza vaccine will be the largest ever, national health officials called on healthcare professionals and the public to improve the "alarmingly low" vaccination rates of recent years. CDC said up to 132 million doses of flu vaccine are expected to be available this year. Last year about 121 million doses were produced, of which 102.5 million were distributed, leaving at least 18 million unused. CDC Director Dr. Julie Gerberding said the production and distribution delays that hurt vaccination coverage last year are not expected this year. CDC officials complained of persistently low vaccination coverage rates in many groups who should be immunized.

CDC specifically recommends flu immunization for children from 6 months to 5 years of age; people with chronic medical conditions such as asthma, diabetes, heart disease, and HIV; pregnant women; people age 50 and older; healthcare professionals; and anyone who has close contact with high-risk groups. Ardis Hoven, a Kentucky infectious-disease specialist and board member of the American Medical Association (AMA), said healthcare workers should use their influence to persuade patients to get flu shots. "Studies show that a healthcare worker's recommendation is one of the strongest factors influencing a person to get vaccinated," she said. The AMA and other medical societies "urge healthcare personnel to use every interaction to talk to people about flu vaccine," she added.

Kerry Weems, acting administrator of the US Center for Medicare and Medicaid Services, stressed that both flu and pneumococcal pneumonia shots are free for Medicare recipients. Yet, "In any given state, at least 20% of people with Medicare aren't getting the flu shot." Pneumococcal pneumonia is the most common bacterial pneumonia, Weems noted. People over age 65 need to get the pneumococcal shot only once, and they can do it when they get their flu shot, he added. Those who have flu have a much higher risk of contracting pneumococcal pneumonia, said Dr. Robert Hopkins Jr of the University of Arkansas for Medical Sciences. Antiviral drugs continue to play an important role in treating and preventing flu, CDC said. For this season, the agency recommends use of oseltamivir (Tamiflu) and zanamivir (Relenza), the newest of four available flu antivirals. The 2 older flu drugs, amantadine and rimantadine, are not recommended because of high levels of resistance.
(CIDRAP 9/19/07)

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USA: GAO finds gaps in federal pandemic planning
In an analysis of the US government's pandemic influenza preparedness plan, the Government Accountability Office (GAO) called on federal agencies to clarify their leadership responsibilities and recommended interagency testing and training exercises to improve preparedness. Feedback from the GAO is primarily aimed at the Homeland Security Council (HSC), the group that authored the 2 pandemic planning documents: the National Strategy for Pandemic Influenza, and the Implementation Plan for the strategy. The 52-page report acknowledges the work federal officials have done to prepare for a flu pandemic, such as establishing an information clearinghouse, developing planning checklists for government agencies and other groups, and building the Strategic National Stockpile of drugs and medical supplies. However, federal plans do not adequately address leadership roles and responsibilities, the report says. For example, the plans don't outline how the secretaries of the departments of Health and Human Services (HHS) and Homeland Security (DHS) would share leadership in a pandemic.

Most of the leadership roles and responsibilities have not been tested in pandemic simulation exercises. "Without rigorous testing, training, and exercising, the administration lacks information to determine whether current and evolving leadership roles and responsibilities are clear and clearly understood or if more changes are needed to ensure clarity," the report states. Of 6 desirable characteristics that the GAO uses to gauge the effectiveness of various federal strategies, investigators found that the national pandemic strategy and plan address only 1: defining problems and assessing risks. The documents partially address 4 of the GAO's criteria: having a clear purpose, scope, and methodology; defining goals, objectives, activities, and performance measures; outlining organizational roles, responsibilities, and coordination; and addressing integration and implementation. The GAO analysis asserts that the pandemic plan lacks mechanisms for monitoring and reporting progress and strongly criticizes the HSC's Dec 2006 status report. In assessing the final criterion—addressing resources—investigators say the HSC did not project how much the strategy would cost or detail how resources would be used.

The GAO makes 2 recommendations to enhance federal preparedness efforts. One is for the HHS and DHS secretaries to work together to conduct testing and training exercises. The other is for the HSC to establish a process and time frame for updating the pandemic implementation plan. The GAO advises the HSC to include the following information in its next plan update: Cost, resources, and allocations needed to complete the action items in the plan; A process for monitoring and publicly reporting on the plan's progress; Clearer linkages with the pandemic strategies and plans of other government agencies; Straightforward descriptions of priorities and relationships among action items and greater use of outcome-oriented performance measures.
(CIDRAP 9/11/07)

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USA: FDA approves FluMist for 2- to 4-year-old children
The Food and Drug Administration's (FDA's) approval of FluMist for children aged 2 through 4 years makes a needle-free influenza vaccine available for small children in the US for the first time. FDA announced its approval of the nasal-spray vaccine, which contains a weakened form of live virus. The vaccine, made by MedImmune, was previously approved only for healthy people between ages of 5 and 49. MedImmune had asked FDA to approve the vaccine for children aged 1 through 4 years with no history of wheezing. But FDA withheld approval of FluMist for children younger than 2 years because clinical trials showed an increased risk of hospitalization and wheezing for that group. The agency also said the vaccine should not be given to children under age 5 who have recurrent wheezing because it may trigger increased wheezing. FDA said its action means 3 flu vaccines are available in the US for children younger than 5 years. Fluzone, made by Sanofi Pasteur Inc., is approved for anyone older than 6 months, and Fluvirin, made by Novartis Vaccines and Diagnostics, is licensed for ages 4 and up.

MedImmune expects to produce about 4.5 million doses of FluMist for the 2007-08 flu season, compared with about 3 million doses last year. The retail price of the vaccine this year is $17.95 per dose. FluMist has been on the market since 2003, but demand for it has been hampered by a higher cost than conventional vaccine and by the requirement to keep it frozen during storage. In January FDA approved a new formulation that requires refrigeration but not freezing.
(CIDRAP 9/20/07)

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USA: Trial of injectable flu drug yields disappointing results
BioCryst Pharmaceuticals, Inc, announced disappointing early results in a phase 2 study of its antiviral drug peramivir, which is seen as a potential new weapon against influenza. Peramivir is a neuraminidase inhibitor that, unlike the licensed antivirals oseltamivir (Tamiflu) and zanamivir (Relenza), is given by intravenous (IV) or intramuscular (IM) injection. Many countries have stockpiled oseltamivir, an oral drug, and zanamivir, inhaled as a powder, in the hope that they will help if the H5N1 virus evolves into a human pandemic strain. The phase 2 double-blind, placebo-controlled trial was designed to see if high doses of IM peramivir could reduce the duration of symptoms in patients with seasonal flu. The study involved 344 patients who had flu that was verified by rapid antigen testing. Patients were randomly assigned to receive injections of a placebo or either 150 mg or 300 mg of peramivir, administered in a single dose within 48 hours after symptom onset.

With 313 patients available for evaluation, researchers found that the peramivir group improved more than placebo group, but the difference was not statistically significant. The improvement over placebo was 22.9 hours in the 150-mg dose group and 21.1 hours in the 300-mg group. The company said it believes the results were negatively affected by shorter needles—used for the phase 2 study but not for the phase 1 study—that may have delivered an adequate injection to only a third of the volunteers. Safety and tolerability were similar for the placebo group and both peramivir groups, BioCryst said. BioCryst will correct the problems identified in the study when it launches a phase 3 study by the end of the year. Another phase 2 study is under way to evaluate the efficacy of IV peramivir in hospital patients with flu, the company said. The study is designed to compare IV peramivir with oral oseltamivir.
(CIDRAP 9/20/07)

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Peru: HIV infections associated with blood transfusion
Health authorities on 13 Sep 2007 placed Peru's 240 blood banks under close scrutiny after 4 patients in less than 6 months were infected with HIV (human immunodeficiency virus) after receiving blood transfusions at public hospitals. "All the blood banks in Peru will undergo a more exhaustive evaluation than the one we have been carrying out since the start of the year [2007], which allowed us to close 30 centers," said Health Minister Carlos Vallejos. Health authorities came in for a firestorm of criticism after media reported that [a 44-year-old woman], was given a bureaucratic run-around for months after she received a transfusion of HIV-tainted blood. Once her case became public, health authorities announced that there were at least 3 other HIV-infected patients, 1 of them an 11-month-old infant. The scare unleashed widespread panic. Vallejos had to issue a special appeal to the public to trust the country's public health services. Adding to the health scare, officials recently announced that 30 patients who went to a social security dialysis center were infected with hepatitis C.
(Promed 9/14/07)

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USA: Animal hides were likely cause of 2 anthrax cases
2 people from Danbury, Conn., were recently diagnosed with cutaneous anthrax infections, probably because of exposure to spores on untanned animal hides brought from Africa. Media reports said the 2 people are members of the same family, and 1 uses animal hides to make and restore drums. William Gerrish, a spokesman for the Connecticut Department of Health, said the 2 patients were recovering and that officials were testing their contacts to see if anyone else was exposed. Samples from the patients' home and a backyard barn tested positive for anthrax, and officials gathered more samples for additional testing. 1 major thoroughfare was closed for more than 24 hours. The New Haven office of the FBI said terrorism was not suspected. Anthrax spores are found in soil in many parts of the world. Anthrax is primarily an animal disease, but naturally occurring cutaneous and inhalational anthrax infections in humans can sometimes result from handling the meat, hair, or hides of infected animals. Only 1 or 2 anthrax cases occur each year in the US. Cutaneous anthrax, caused by Bacillus anthracis spores, typically appears as a skin ulcer surrounded by painless swelling. The infection resolves with antibiotic treatment. Human-to-human transmission is rare and generally can occur only when patients have draining lesions. African hides used in drum-making were also linked to an anthrax case in 2006. A drummer from New York City became ill with inhalational anthrax after a performance in Pennsylvania. He was hospitalized for a month, but has since returned to drum-making.
(CIDRAP 9/10/07; Promed 9/6/07)

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USA (Arizona): Human case of plague reported
Arizona's first case of plague since 2000 has been reported in an adult female in Apache County. The woman became ill early Sep 2007 from a flea bite at her home in northern Arizona. She is now recovering after receiving the appropriate antimicrobial treatment. In a community northeast of Flagstaff in Coconino County, an outbreak of plague involving prairie dogs is occurring. Many rodents are dying from the disease and are leaving behind infected fleas. County health and Northern Arizona University officials are closely monitoring and responding to this situation. Response has included flea collecting and testing, and extensive prevention education and outreach to people in affected areas. During the last 30 years (1977-2006), 48 cases of plague have been reported in Arizona, 8 of which were fatal. The plague risk has been relatively low during the last 6 years due to drought conditions and high summer temperatures. Plague can be transmitted to humans by flea bites or by direct contact with infected animal tissues during skinning or handling of game animals. In very rare cases, plague can be spread from person-to-person, or cat-to-person, by airborne transmission. People or animals, particularly cats, infected with plague pneumonia can transmit the bacteria by coughing or sneezing in the face of another person or animal.
(Promed 9/14/07)

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USA (Texas): Cutaneous leishmaniasis cases in North Texas
A rare infectious skin disease is popping up in North Texas. Leishmaniasis is found in South America, Mexico, and the Middle East. But now, it has made an appearance locally. The 9 cases found in North Texas over the past 18 months did not originate in the Middle East. The particular strain that doctors are finding is called [Leishmania] mexicana, and it originated here. Dr. Doug Hardy, an infectious disease specialist at UT (University of Texas) Southwestern, said, "They can look kind of like an abscess, but they're not really an abscess. They can look like an ulcer. It might look kind of wet, but it doesn't really drain. It's a little parasite, and it doesn't respond to antibiotics. It doesn't respond to the standard treatments that we might use on a fungal skin infection." Leishmania is a single cell protozoan parasite.

North Texas doctors must have a high index of suspicion and understand that this organism must now be considered endemic in this area, said Dr. Kent Aftergut, a clinical instructor of dermatology at UT Southwestern and in private practice at Methodist Charlton Medical Center. "Luckily, all of the leishmaniasis cases in North Texas that have been cultured have grown Leishmania mexicana, which is less dangerous than other forms of the parasite," he said. "It makes skin sores, but the infection doesn't spread and become a full body disease like some of the others species of Leishmania. Usually, if patients have a normal immune system, the sores will resolve in 6 to 12 months and won't make the patients ill."

In North Texas, doctors suspect that the process leading to human infection begins when a sand fly bites a rodent which carries the parasite. When the sand fly later bites a person, the sores may develop. For many years, sporadic cases have been seen in South Texas. But no one has ever reported cases this far north, Dr. Aftergut said. Dr. Aftergut said using insecticides, bug repellant and protective clothing while working in areas where sand flies might be present should help reduce exposure.
(Promed 9/15/07, 9/16/07)

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USA: House panel sees CDC errors in case of traveling TB patient
US health officials failed to follow international health regulations and made other errors in dealing with Andrew Speaker, the man with drug-resistant tuberculosis who sparked a health scare by traveling overseas in May, according to a report released by Democrats in Congress. The report by the majority staff of the House Committee on Homeland Security says CDC delayed informing WHO that Speaker was traveling internationally despite having what was thought at the time to be extensively drug-resistant tuberculosis (XDR-TB). Under the International Health Regulations, CDC should have informed the WHO immediately, but instead the agency waited 2 days, the report says. The report also faults the Department of Homeland Security (DHS) for its role in various aspects of the episode and says it is not clear whether the federal agencies are working hard enough to prevent similar problems in the future.

The report says CDC "did not properly adhere to the International Health Regulations" in handling the case. The agency told US Customs and Border Protection (CBP) May 22, a day after the positive test for XDR TB, that Speaker was believed to be a significant public health risk, the report says. The report says, "Under the International Health Regulations, CDC should have informed the World Health Organization (WHO) that same day of this significant public health risk. Instead, CDC delayed an additional 48 hours before informing WHO on May 24. Had the CDC informed the WHO earlier of the situation, European authorities may well have been able to apprehend Mr. Speaker while he was still overseas."

The report also says CDC, in managing the incident, "relied too heavily on strong interpersonal relationships" with officials in other US and foreign agencies, rather than using formal channels. For example, the agency worked with CBP personnel at the Atlanta quarantine station instead of CBP officials in Washington, DC. Also, in communicating with the Italian Ministry of Health, the CDC worked with a former CDC employee who was on the staff there. The committee also questions the CDC's handling of the problem of returning Speaker to the US without endangering anyone else. The CDC was considering various options, including using its own plane, when it learned May 24 that Speaker had already re-entered the country, the report notes.

Other findings in the report include: Government officials could legally have prevented Speaker from traveling within, outside, and back into the United States, but failed to use "aggressive" measures soon enough; The "egregious failure" of the CBP to keep Speaker from re-entering the country remains unexplained, but the CBP has made changes to prevent such mistakes; It took several hours for DHS to get Speaker on the Transportation Security Administration's "no fly" list, because the fact that he was not a terrorist caused confusion about which list he could be put on.
(CIDRAP 9/13/07)

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Africa
Nigeria (Nasarawa): Avian influenza reported in poultry
Over 1052 birds have so far been culled in Panda Development Area of Nasarawa State in the wake of avian influenza that affected the area. UNICEF (UN Children's Fund) field officer for avian influenza, Alhaji Bala Hassan, said the efforts of the people of the area in reporting cases of sick or dead birds as well as their contributions towards the depopulation exercise was commendable. Bala cautioned the people against taking sick or dead birds for granted and to ensure that poultry meat and eggs are properly cooked before consumption. He advised parents to keep their children away from sick or dead birds and advised them to wash their hands. The UNICEF focal person on avian influenza control in the Ministry of Information, Mallam Abubakar Tanko, advised the people to keep away from using poultry droppings as manure following the dangers associated with the confirmation of H5N1 virus in the area. The district head of Kondoro, Alhaji Muha-mmeadu Habu, called on the state government to come to their aid in the payment of compensations due to the birds they have lost.
(Promed 9/21/07)

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1. Updates
Avian/Pandemic influenza updates
- UN: http://www.un-influenza.org/ : the website has been moved and updated. Also, http://www.irinnews.org/Birdflu.asp provides information on avian influenza.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Link to supplement to Journal of Wildlife Diseases on avian influenza.
- OIE: http://www.oie.int/eng/en_index.htm.
- US CDC: http://www.cdc.gov/flu/avian/index.htm. News on federal updates.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/.
- Health Canada: information on pandemic influenza: http://www.influenza.gc.ca/index_e.html.
- CIDRAP: http://www.cidrap.umn.edu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. Link to National Influenza Centers in PAHO Member States.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp. Updated 21 Sep 2007.
(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Cholera, diarrhea & dysentery
Philippines (Shariff Kabunsuan)
2 people died, while 45 others fell ill from diarrhea in Sitio Upper Tubuan, Barangay Lahangkob, North Upi in the province of Shariff Kabunsuan, the Bureau of Public Information office of the Autonomous Region in Muslim Mindanao (BPI-Armm) reported 19 Sep 2007. An Emergency Medical Response (EMR) group had been formed after the Provincial Health Office of Maguindanao reported the alarming case. The EMR, together with the regional, provincial, and rural health units and district hospital staff, responded by visiting the affected area 16 Sep 2007. After conducting check-ups and epidemiologic investigations of about 300 families in the area, at least 47 cases of diarrhea were confirmed during the consultation. The response team collected stool specimens through rectal swabbing, and conducted investigations to identify the source of infection. The response team checked environmental sanitation and found that poor hygiene and lack of sanitation facilities contributed to the occurrence of the disease.
(Promed 9/19/07)

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Dengue
China (Guangdong)
A total of 25 people have been confirmed to have contracted dengue fever in Zhuhai, a city in South China's Guangdong Province, in the last 2 weeks, the city's vice mayor Deng Qunfang said 6 Aug 2007. Authorities have also found another 16 suspected cases since 22 Aug [2007], Deng said. Deng attributed the outbreak to the rainy weather which favored mosquito reproduction but said the outbreak had been brought under control. The city set up an emergency headquarters to fight the disease 5 Sep 2007 and has launched a mass campaign to clean up the city and kill mosquitoes.
(Promed 9/8/07)

Philippines (Laguna)
The provincial health office in Laguna reported 223 new dengue victims in Aug 2007, or a 36-percent increase compared to Jul 2007. As of Aug 2007, the total number of victims reported since Jan [2007] has increased to 846 from 623 in July. Over the same period, the total number of dengue fatalities increased to 8, up by 2 from a total of 6 recorded in Jul [2007].
(Promed 9/8/07)

Philippines (Iloilo City)
Dengue fever cases in Iloilo City continue to increase in number, with 11 deaths already reported as of Aug 2007. The latest report showed that 44 of the city's 180 barangays [subdivisions] are already affected by dengue. For this month alone [Aug 2007], the report showed that there were 68 dengue cases, which is some 20 percent higher compared to the 14 cases monitored in Aug 2006. From January to August this year [2007], dengue cases here already totaled 189. The figure is 50-60 percent higher compared to the 96 cases during the same period last year. There were only 4 dengue deaths recorded in 2006.
(Promed 9/8/07)

Philippines (Cebu City)
The [Cebu] City Health Department will recommend that 2 southern barangays [districts] in Cebu City be placed under a state of calamity after dengue claimed the lives of 7 children in less than 2 months. City health officer Fe Cabugao will endorse to the City Council to declare Bulacao and Pardo in a state of calamity due to dengue outbreak in the 2 villages. The health department recorded deaths of 3 children aged 5 years in sitio Tabacunal, barangay Pardo, and 4 children also died of dengue in sitios Villabulsita and Charlieville in Bulacao. Ogan said officials were also alarmed by the 13 to 15 new cases each in Pardo and Bulacao. Pardo's dengue cases from Jan to 10 Sep in 2007 reached 33 and 34 in Bulacao. A total of 697 dengue cases with 18 deaths were reported in Cebu City over the same period. The figure was 10 per cent higher than the 528 dengue cases with 15 deaths reported from Jan to 10 Sep in 2006.
(Promed 9/18/07)

Taipei
Another 89 cases of dengue fever were reported around Taiwan last week [9-15 Aug 2007], including 44 cases involving residents in a veterans' home in Tainan City's East District, a Department of Health (DOH) official said 21 Aug 2007. Chou Chih-hau, deputy director-general of the DOH's Center for Disease Control (CDC), said the cluster in Tainan was the largest in nearly 10 years. The first case of the cluster was reported 8 Aug 2007 followed by more cases 13, 14 Aug 2007. Tainan City's Health Bureau and the Taiwan CDC then started examinations of residents and inspected the environment around the veterans' home, which houses more than 400 veterans in their 70s or 80s. The CDC discovered that 44 residents were infected with dengue fever and found that drains on the roof and water reservoirs of the facility's air conditioners were the main mosquito breeding areas. Chou reminded nursing homes to heed the situation and clean water storage containers around residences. He said the North District of Tainan City also reported its second indigenous dengue fever case--a 2-year-old girl who was diagnosed with the disease 6 Aug 2007. She was discharged from the hospital 17 Aug.

In Kaohsiung County officials were mobilized for an urgent undertaking aimed at preventing an outbreak of dengue fever. County Magistrate Yang Chiu-hsiung ordered officials to reinforce efforts to cleanse mosquito-breeding sites after the southern county reported last week its first indigenous dengue fever case this summer. The patient, a woman aged over 50, works in the neighboring city of Kaohsiung; Kaohsiung City is one of southern Taiwan's dengue-affected areas, with 52 cases of indigenous dengue fever reported so far since the beginning of the summer.
(Promed 9/8/07)

Singapore
On 10 Sep 2007, 11 new cases of dengue were reported, 4 more than 9 Sep 2007. Of these new cases, 3 are from Bukit Batok. This brings the total number of cases from Bukit Batok so far this year [2007] to 114. According to the National Environment Agency (NEA), the area continues to be the number one hotspot, with the highest number of infections reported in Bukit Batok Streets 31, 32, and 34. Most breeding grounds have been found to be indoors. Hong Kah Town Council, which oversees the common areas in Bukit Batok, said it is continuing with its stepped up efforts to ensure that the affected places do not remain a hotspot. These include increasing the frequency of inspections at potential breeding grounds around the estate, and deploying staff from other estates to help out.
(Promed 9/18/07)

Viet Nam
According to the Health Ministry, Viet Nam has had 52 107 cases of dengue fever so far in 2007, including 49 deaths. Southern provinces comprising Tien Giang, Dong Thap, An Giang, Kien Giang and Soc Trang have witnessed the highest numbers of dengue fever patients. The number of dengue fever cases this year is the highest since 1999. The Health Ministry has set up 6 working groups to evaluate the dengue fever situation in 17 southern, 4 central and 3 northern provinces of high risk. The ministry has also provided 3000 liters of anti-mosquito chemical for the HCM City Pasteur Institute to kill mosquitoes in the south, and 2670 liters of solution for vector mosquito control for provinces of high risk.
(Promed 9/8/07)

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West Nile Virus
Canada
Human cases were reported for week 36 (as of 8 Sep 2007) from the following provinces: Province / Neurological / Non-Neurological / Unclassified-Unspecified / Total / Asymptomatic

Ontario / 1 / 5 / 0 / 6 / 3
Manitoba / 34 / 185 / 277 / 496 / 7
Saskatchewan / 30 / 344 / 662 / 1036 / 18
Alberta / 11 / 234 / 0 / 245 / 1
British Columbia / 4 / 3 / 0 / 7* / 0
TOTALS / 80 / 771 / 939 / 1790 / 29
* Infection acquired while traveling outside the province
(Promed 9/20/07)

USA
2007 West Nile virus activity in the United States (through 18 Sep 2007) State / Neuroinvasion/West Nile fever/ Other, Unspecified/ Total/ Fatalities:

Alabama / 12 / 1 / 0 / 13 / 3
Arizona / 10 / 4 / 17 / 31 / 0
Arkansas / 7 / 1 / 0 / 8 / 1
California / 88 / 134 / 9 / 231 / 13
Colorado / 60 / 269 / 0 / 329 / 4
Connecticut / 3 / 1 / 0 / 4 / 0
Florida / 3 / 0 / 0 / 3 / 1
Georgia / 14 / 8 / 2 / 24 / 1
Idaho / 1 / 69 / 0 / 70 / 0
Illinois / 20 / 5 / 3 / 28 / 2
Indiana / 3 / 4 / 0 / 7/ 0
Iowa / 6 / 8 / 0 / 14 / 0
Kansas / 9 / 17 / 0 / 26 / 0
Kentucky / 2 / 0 / 0 / 2 / 0
Louisiana / 1 / 1 / 0 / 2 / 0
Maryland / 1 / 1 / 1 / 3 / 0
Massachusetts / 1 / 2 / 0 / 3 / 0
Michigan / 1 / 0 / 0 / 1 / 0
Minnesota / 32 / 46 / 0 / 78 / 0
Mississippi / 21 / 38 / 0 / 59 / 1
Missouri / 25 / 5 / 0 / 30 / 1
Montana / 32 / 103 / 0 / 135 / 3
Nebraska / 8 / 62 / 0 / 70 / 3
Nevada / 2 / 4 / 3 / 9 / 0
New Mexico / 19 / 12 / 0 / 31 / 2
New York / 4 / 0 / 0 / 4 / 1
North Dakota / 38 / 241 / 0 / 279 / 2
Ohio / 1 / 2 / 0 / 3 / 0
Oklahoma / 30 / 23 / 1 / 54 / 4
Oregon / 3 / 8 / 0 / 11 / 0
Pennsylvania / 1 / 0 / 0 / 1 / 0
South Carolina / 1 / 2 / 0 / 3 / 0
South Dakota / 41 / 132 / 0 / 173 / 4
Tennessee / 2 / 1 / 0 / 3 / 0
Texas / 46 / 11 / 0 / 57 / 2
Utah / 10 / 16 / 0 / 26 / 0
Virginia / 2 / 0 / 0 / 2 / 0
Wisconsin / 2 / 1 / 0 / 3 / 0
Wyoming / 11 / 129 / 12 / 152 / 1
TOTALS / 573 / 1361 / 48 / 1982 / 49
(Promed 9/20/07)

West Nile Virus Update--United States, January 1-September 11, 2007 As of Sep 11, 2007 a total of 38 states have reported 1,395 cases of human WNV illness to CDC. A total of 770 (56%) cases for which such data were available occurred in males; median age of patients was 49 years (range: 15 months--96 years). Dates of illness onset ranged from Jan 8 to Sep 7; a total of 38 cases were fatal. A total of 136 presumptive West Nile viremic blood donors (PVDs) have been reported during 2007. Of the 136 PVDs, 2 persons (median age: 66 years; range: 60--71 years) subsequently had neuroinvasive illness, and 31 persons (median age: 49 years; range: 18--79 years) subsequently had West Nile fever. http://cdc.gov/mmwr/preview/mmwrhtml/mm5636a3.htm
(MMWR September 14, 2007 / 56(36);936-937)

Russia (Volgograd, Rostov)
This year (2007), 22 cases of West Nile virus (WNV) have been registered in the Volgograd [region]: 15 cases in inhabitants of Volgograd (city), 6 cases in Voljskiy [also known as Volzhskiy] district, and 1 case in Sredneakhtubinsky district. Of these, 2 people died as a result of immune system weakening. WNV was first detected in [Russia] in 1999, when more than 300 people contracted the disease and 30 cases ended with a fatal outcome. Volgograd is considered an endemic zone for WNV.

The latest case of the disease was recorded last week [27 Aug - 2 Sep 2007] in Rostov. Reportedly mosquitoes infected by WN virus have been detected by experts in the Proletarsky, Neklinovsky, Azovsky, Myasnikovsky, Salsky, & Kamensky districts. In Rostov-on-Don they are distributed in the Kumzensky grove, in flooded cellars of the houses, and sewage collectors. Reportedly mosquitoes infected by WN virus from wild birds can be found in the open in other districts of the region.
(Promed 9/3/07, 9/6/07)

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2. Articles
CDC EID Journal, Volume 13, Number 9—Sep 2007
CDC Emerging Infectious Diseases Journal Sep 2007 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. Expedited articles can be viewed at: http://www.cdc.gov/ncidod/eid/upcoming.htm.

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Potential for early warning of viral influenza activity in the community by monitoring clinical diagnoses of influenza in hospital emergency departments
Wei Zheng. BMC Public Health 2007, 7:250doi:10.1186/1471-2458-7-250. http://www.biomedcentral.com/1471-2458/7/250/abstract
Abstract: Background Although syndromic surveillance systems are gaining acceptance as useful tools in public health, doubts remain about whether the anticipated early warning benefits exist. Many assessments of this question do not adequately account for the confounding effects of autocorrelation and trend when comparing surveillance time series and few compare the syndromic data stream against a continuous laboratory-based standard. We used time series methods to assess whether monitoring of daily counts of Emergency Department (ED) visits assigned a clinical diagnosis of influenza could offer earlier warning of increased incidence of viral influenza in the population compared with surveillance of daily counts of positive influenza test results from laboratories. Methods For the five-year period 2001 to 2005, time series were assembled of ED visits assigned a provisional ED diagnosis of influenza and of laboratory-confirmed influenza cases in New South Wales (NSW), Australia. Poisson regression models were fitted to both time series to minimise the confounding effects of trend and autocorrelation and to control for other calendar influences. To assess the relative timeliness of the two series, cross-correlation analysis was performed on the model residuals. Modelling and cross-correlation analysis were repeated for each individual year. Results Using the full five-year time series, short-term changes in the ED time series were estimated to precede changes in the laboratory series by three days. For individual years, the estimate was between three and 18 days. The time advantage estimated for the individual years 2003-2005 was consistently between three and four days. Conclusions Monitoring time series of ED visits clinically diagnosed with influenza could potentially provide three days early warning compared with surveillance of laboratory-confirmed influenza. When current laboratory processing and reporting delays are taken into account this time advantage is even greater.

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Influenza Vaccination Coverage Among Children Aged 6-59 Months--Six Immunization Information System Sentinel Sites, United States, 2006-07 Influenza Season
“In June 2006, the Advisory Committee on Immunization Practices (ACIP) expanded its 2004 recommendation for routine influenza vaccination of children aged 6--23 months to include children aged 24--59 months. The 2006 ACIP recommendations also reemphasized that previously unvaccinated children aged <9 years should receive 2 doses of influenza vaccine administered at least 1 month apart to be fully vaccinated. In 2007, using data from six immunization information system (IIS) sentinel sites, CDC conducted the first assessment of influenza vaccination coverage among children aged 6--59 months during the 2006--07 influenza season. The findings demonstrated that, at all six sites, <30% of children aged 6--23 months and <20% of children aged 24--59 months were fully vaccinated. Vaccination coverage data from national and state surveys for an influenza season generally are not available until the next influenza season. Rapid assessment of influenza vaccination coverage can help direct activities of state and local public health agencies aimed at increasing the number of children fully vaccinated against influenza. . .” http://cdc.gov/mmwr/preview/mmwrhtml/mm5637a3.htm
(MMWR September 21, 2007 / 56(37);963-965)

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Influenza Vaccination Coverage Among Children Aged 6-23 Months--United States, 2005--06 Influenza Season
“Children aged <2 years are at increased risk for influenza-related hospitalizations, and those aged <5 years have more influenza-related health-care visits than older children. In 2004, the Advisory Committee on Immunization Practices (ACIP) recommended annual influenza vaccination of children aged 6--23 months. Two doses, at least 4 weeks apart, were recommended to fully vaccinate children aged <9 years who were receiving influenza vaccination for the first time. To assess influenza vaccination coverage among children aged 6--23 months during the 2005--06 influenza season, data from the 2006 National Immunization Survey (NIS) were analyzed. This report describes the results of that analysis, which indicated that 31.9% of children in this age group received at least 1 dose of influenza vaccine and 20.6% were fully vaccinated according to ACIP recommendations; however, results varied substantially among states. The results underscore the need to continue to monitor influenza vaccination coverage among young children, develop systems to provide childhood influenza vaccination services more efficiently, and increase awareness among health-care providers and caregivers about the effectiveness of influenza vaccination among young children. . .”
http://cdc.gov/mmwr/preview/mmwrhtml/mm5637a2.htm
(MMWR September 21, 2007 / 56(37);959-963)

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State-Specific Influenza Vaccination Coverage Among Adults Aged >18 Years--United States, 2003-04 and 2005-06 Influenza Seasons
“Influenza epidemics occur seasonally and result in substantial morbidity and mortality among adults in the United States. Adult groups included in the 2007 Advisory Committee on Immunization Practices (ACIP) recommendation for annual influenza vaccination are persons aged 18--49 years with high-risk conditions (i.e., conditions associated with an increased risk for complications from influenza), persons aged >50 years, health-care personnel, and others who are household contacts or caregivers of persons at high risk (e.g., persons with high-risk conditions or children aged <59 months). In addition, adults who want to reduce the risk for becoming ill with influenza or of transmitting influenza to others should be vaccinated. Healthy People 2010 (HP2010) objectives include increasing vaccination levels to 90% for adults aged >65 years (objective 14-29a) and 60% for persons aged 18--64 years who have one or more high-risk conditions (objective 14-29c). From the 1992--93 through 2003--04 influenza seasons, seasonal influenza vaccination coverage estimates (based on Behavioral Risk Factor Surveillance System [BRFSS] data) among adults aged >65 years trended upward, except for three seasons (1997--98, 1999--00, and 2000--01) when no increases occurred. To evaluate recent state-specific progress toward the HP2010 objectives, CDC compared data from the 2004 and 2006 BRFSS surveys, which reflected vaccinations received during the 2003--04 and 2005--06 influenza seasons; data from the 2004--05 influenza season, which have been published previously, were not included in this comparison because that season was marked by a substantial shortage of influenza vaccine. This report describes the results of the analysis, which indicated that influenza vaccination coverage for the 2005--06 season did not return to levels observed before the vaccine shortage of 2004--05 and remained substantially below HP2010 targets. Comprehensive measures are needed to improve influenza vaccination coverage among adult populations in the United States, including increasing adoption of recommended adult immunization practices by health-care providers, raising public awareness about influenza vaccination, vaccinating throughout the influenza season, and ensuring stable supplies of readily available vaccine. . .” http://cdc.gov/mmwr/preview/mmwrhtml/mm5637a1.htm
(MMWR September 21, 2007 / 56(37);953-959)

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Ocular and Respiratory Illness Associated with an Indoor Swimming Pool--Nebraska, 2006
“On December 26, 2006, the Nebraska Department of Health and Human Services (NDHHS) received a report of a child hospitalized in an intensive care unit for severe chemical epiglottitis and laryngotracheobronchitis after swimming in an indoor motel swimming pool. The pool was inspected the same day and immediately closed by NDHHS because of multiple state health code violations. NDHHS initiated an outbreak investigation to identify additional cases and the cause of the illness. This report describes the results of that investigation, which indicated that 24 persons became ill, and the outbreak likely was the result of exposure to toxic levels of chloramines that had accumulated in the air in the enclosed space above the swimming pool. This outbreak highlights the potential health risks from chemical exposure at improperly maintained pools and the need for properly trained pool operators to maintain water quality. . .” http://cdc.gov/mmwr/preview/mmwrhtml/mm5636a1.htm
(MMWR September 14, 2007 / 56(36);929-932)

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Multistate Outbreaks of Salmonella Infections Associated with Raw Tomatoes Eaten in Restaurants--United States, 2005-006
“During 2005--2006, four large multistate outbreaks of Salmonella infections associated with eating raw tomatoes at restaurants occurred in the United States. The four outbreaks resulted in 459 culture-confirmed cases of salmonellosis in 21 states. This report describes the epidemiologic, environmental, and laboratory investigations into these four outbreaks by state and local health departments, national food safety agencies, and CDC. The results of these investigations determined that the tomatoes had been supplied to restaurants either whole or precut from tomato fields in Florida, Ohio, and Virginia. These recurrent, large, multistate outbreaks emphasize the need to prevent Salmonella contamination of tomatoes early in the production and packing process. Current knowledge of mechanisms for tomato contamination and methods of eradication of Salmonella in tomatoes is incomplete; the agricultural industry, food safety agencies, and public health agencies should make tomato-safety research a priority. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a3.htm
(MMWR September 7, 2007 / 56(35);909-911)

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Mucosal immunization with a novel nanoemulsion-based recombinant anthrax protective antigen vaccine protects against Bacillus anthracis spore challenge
Bielinska AU et al. Infect Immun 2007 Aug;75(8):4020-29. http://iai.asm.org/cgi/content/abstract/75/8/4020
Abstract: The currently available commercial human anthrax vaccine requires multiple injections for efficacy and has side effects due to its alum adjuvant. These factors limit its utility when immunizing exposed populations in emergent situations. We evaluated a novel mucosal adjuvant that consists of a nontoxic, water-in-oil nanoemulsion (NE). This material does not contain a proinflammatory component but penetrates mucosal surfaces to load antigens into dendritic cells. Mice and guinea pigs were intranasally immunized with recombinant Bacillus anthracis protective antigen (rPA) mixed in NE as an adjuvant. rPA-NE immunization was effective in inducing both serum anti-PA immunoglobulin G (IgG) and bronchial anti-PA IgA and IgG antibodies after either one or two mucosal administrations. Serum anti-PA IgG2a and IgG2b antibodies and PA-specific cytokine induction after immunization indicate a Th1-polarized immune response. rPA-NE immunization also produced high titers of lethal-toxin-neutralizing serum antibodies in both mice and guinea pigs. Guinea pigs nasally immunized with rPA-NE vaccine were protected against an intradermal challenge with ~1,000 times the 50% lethal dose (~1,000x LD50) of B. anthracis Ames strain spores (1.38 x 103 spores), which killed control animals within 96 h. Nasal immunization also resulted in 70% and 40% survival rates against intranasal challenge with 10x LD50 and 100x LD50 (1.2 x 106 and 1.2 x 107) Ames strain spores. Our results indicate that NE can effectively adjuvant rPA for intranasal immunization. This potentially could lead to a needle-free anthrax vaccine requiring fewer doses and having fewer side effects than the currently available human vaccine.

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On Prions, Proteasomes, and Mad Cows
Alfred L. Goldberg. N Engl J Med. 2007 Sep 13;357(11):1150-2 http://content.nejm.org/cgi/content/full/357/11/1150
“All cells have the capacity to selectively degrade misfolded intracellular proteins, which, if they accumulated, could interfere with normal function and could be toxic. Such proteins may arise by mutation, errors in gene expression, failure to fold correctly, spontaneous denaturation, or postsynthetic damage (for example, by oxygen radicals). How often such events occur in cells is uncertain, largely because the ubiquitin–proteasome pathway rapidly degrades such aberrant proteins, including those that cause various inherited diseases, such as cystic fibrosis and certain hemoglobinopathies. . .”

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The Continuing Spread of West Nile Virus in the Western Hemisphere
Duane J. Gubler. Clinical Infectious Diseases. 2007;45:1039-1046. http://www.journals.uchicago.edu/CID/journal/issues/v45n8/51212/brief/51212.abstract.html
West Nile virus (WNV) has historically been considered to be among the least virulent of the Japanese serogroup viruses of the family Flaviviridae, genus Flavivirus. However, recent epidemics associated with severe and fatal neuroinvasive disease have changed that perception. The emergence of a virus subtype with greater epidemic potential and virulence in the early 1990s facilitated the geographic expansion and westward spread of WNV; in 1999, it first appeared in the western hemisphere. Because of the broad host and vector range, the virus has become established in much of the region, and there is little chance that it will be eliminated. Transmission is difficult to predict and even more difficult to prevent and control. The cost-effectiveness of human WNV vaccines is uncertain. The building of laboratory diagnostic, epidemiologic, and vector-control capacity in WNV-enzootic countries is critical to the development of effective prevention and control strategies for WNV infection, as well as for other potential emerging vectorborne viral diseases.

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3. Notifications
New avian influenza reports from the ECDC
From the European Centre for Disease Prevention and Control (ECDC), released Sep 20, 2007:
- Technical report: Expert advisory groups on human H5N1 vaccines: public health and operational questions.
- Technical report: Expert advisory groups on human H5N1 vaccines: scientific questions

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Seattle Influenza Vaccine Symposium, Oct. 15
From Betz Halloran and Ira Longini, Organizers: This note is to remind you of the upcoming Seattle Influenza Vaccine Symposium sponsored by the Vaccine and Infectious Disease Institute. The symposium will be held at the Pelton Auditorium on the Fred Hutchinson Cancer Research Center campus Oct 15, 2007. This 1-day symposium will include presentations by renowned guests Albert Osterhaus from Emmaus University, Paul Glezen from Baylor College of Medicine and Michael Katze from the University of Washington. If you have any questions, please feel free to contact Rose Hesselbrock or Mary Lou Gamba at 206-667-7000.
(UW Department of Global Health 9/11/07)

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APUA Second World Congress
APUA is pleased to announce its Second World Congress: Devising Improved Methods for Identification and Treatment of Infectious Disease, to be held 28-30 Oct 2007 at the Hyatt Regency Hotel in Boston, Massachusetts. The Congress will engage a full range of stakeholders in industry, government and academia. In addition to highlighting new anti-infective drug innovation and development and new immunogenic therapeutic advances, the sub-focus of the conference will be development and implementation of infectious disease diagnostics in resource-poor settings. 6 session tracks are: Diagnostics; Drug Policy and Economic Burden; Biodefense; Infection Control; Drug Innovation & Development; Immunomodulation. A complete conference brochure is available on the APUA website at <http://www.apua.org>. For more information on the conference, please contact Karrie-Ann Toews at or 617-636-4021.
(Promed 9/13/07)

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MMWR Podcasts
In October 2006, MMWR initiated a series of weekly podcast recordings based on MMWR reports. Unlike the MMWR reports themselves, which are aimed primarily at medical and public health professionals, the podcasts are intended for lay audiences. Three separate podcasts are produced from the same report: A Cup of Health with CDC, featuring 5- to 8-minute interviews with authors or spokespersons; A Minute of Health with CDC, a 59-second capsulized version of a report; and Un Minuto de Salud con los CDC, the same version of the report translated into Spanish. MMWR podcasts are available from the MMWR website (http://www.cdc.gov/mmwr) or via the CDC podcast page (http://www2a.cdc.gov/podcasts). The podcasts can be accessed as downloads or RSS (really simple syndication) feeds; instructions are available at both Internet sites. http://cdc.gov/mmwr/preview/mmwrhtml/mm5636a4.htm
(MMWR September 14, 2007 / 56(36);937)

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FDA approves Acambis smallpox vaccine
A second-generation smallpox vaccine made by the British biotechnology company Acambis plc and stockpiled by the US government as protection against bioterrorist attacks has been approved by the US Food and Drug Administration (FDA). FDA announced its approval of the vaccine, called ACAM2000, Sep 1, 2007. It "is intended for the inoculation of people at high risk of exposure to smallpox and could be used to protect individuals and populations during a bioterrorist attack," FDA said. The vaccine also will be used to protect US military personnel. More than 1.2 million military members serving in high-risk areas have received smallpox shots since 2003, according to Department of Defense (DoD) data. Acambis said it has already supplied 192.5 million doses of ACAM2000 to CDC for the Strategic National Stockpile. The product makes up the majority of the US supply of smallpox vaccines. Federal officials said the stockpile is large enough to protect the entire US population against smallpox.

ACAM2000 uses vaccinia virus, a relative of smallpox, and is derived from Dryvax, an older vaccine that was grown on the skin of calves and used in global smallpox eradication programs. The newer vaccine is grown in cell culture, which is thought to produce a purer vaccine with less risk of causing rare but serious complications. Acambis states, "ACAM2000 was developed to be a modern smallpox vaccine with a safety and efficacy profile comparable to the US's licensed previous vaccine but manufactured using the latest production techniques."

FDA said ACAM2000 was tested in people who had never received a smallpox shot before and in people who had been vaccinated many years earlier. The percentage of previously unvaccinated volunteers who had a successful immunization reaction was similar to that for Dryvax, and the vaccine also was found acceptable as a booster in those who had been vaccinated before. People who have weakened immunity should not receive conventional smallpox vaccine except in emergencies, according to the Department of Health and Human Services (HHS). The ACAM2000 license requires that providers and recipients of the vaccine be educated about the risks. Vaccinees must be given an FDA-approved medication guide that provides information about care of the vaccination site as well as potential serious side effects.

In studies, about 1 in 175 first-time smallpox vaccinees experienced myocarditis and/or pericarditis, FDA said. Of 10 adults who were affected, 4 had no symptoms, and all but one recovered from their symptoms by the end of the study. In the US military vaccination program, 140 cases of myopericarditis had been recorded as of May 2007, according to the DoD's online safety summary. Detailed follow-up cardiac testing was done in 64 cases and yielded normal results.
(CIDRAP 9/4/07)

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Redefining Readiness
New preparedness site from the New York Academy of Medicine focusing on sheltering in place.
http://www.redefiningreadiness.net/index.html. The website content includes: - Overview of Redefining Readiness: 9/19/07 Congressional Briefing Statement
- The Redefining Readiness Study: Uncovering a Fundamental Flaw in Emergency Preparedness
- The Redefining Readiness Local Demonstration Projects: Fixing the Flaw by Grounding Preparedness in the Knowledge and Experiences of People Who Need to be Protected in Emergencies
- New Practical Tools To Make Protection Possible: Preparing to Shelter in Place; Preparing for Deadly Infectious Disease Outbreaks; Engaging the Public in Preparing for Other Emergencies.

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